Experimental results and clinical implications of the four R's in fractionated radiotherapy

Copper homeostasis and cuproptosis in radiation-induced injury

Radiation therapy for cancer treatment brings about a series of radiation injuries to normal tissues. In recent years, the discovery of copper-regulated cell death, cuproptosis, a novel form of programmed cell death, has attracted widespread attention and exploration in various biological functions and pathological mechanisms of copper metabolism and cuproptosis. Understanding its role in the process of radiation injury may open up new avenues and directions for exploration in radiation biology and radiation oncology, thereby improving tumor response and mitigating adverse reactions to radiotherapy. This review provides an overview of copper metabolism, the characteristics of cuproptosis, and their potential regulatory mechanisms in radiation injury.

Hypofractionated Stereotactic Radiosurgery in the Management of Brain Metastases

Stereotactic radiosurgery (SRS) is an important weapon in the management of brain metastases. Single-fraction SRS is associated with local control rates ranging from approximately 70% to 100%, which are largely dependent on lesion and postoperative cavity size. The rates of local control and improved neurocognitive outcomes compared with conventional whole-brain radiation therapy have led to increased adoption of SRS in these settings. However, when treating larger targets and/or targets located in eloquent locations, the risk of normal tissue toxicity and adverse radiation effects within healthy brain tissue becomes significantly higher. Thus, hypofractionated SRS has become a widely adopted approach, which allows for the delivery of ablative doses of radiation while also minimizing the risk of toxicity. This approach has been studied in multiple retrospective reports in both the postoperative and intact settings. While there are no reported randomized data to date, there are trials underway evaluating this paradigm. In this article, we review the role of hypofractionated SRS in the management of brain metastases and emerging data that will serve to validate this treatment approach. Pertinent articles and references were obtained from a comprehensive search of PubMed/MEDLINE and clinicaltrials.gov .

Modelling Cellular Response to Ionizing Radiation: Mechanistic, Semi-Mechanistic, and Phenomenological Approaches - A Historical Perspective

Radiation research is a multidisciplinary field, and among its many branches, mathematical and computational modelers have played a significant role in advancing boundaries of knowledge. A fundamental contribution is modelling cellular response to ionizing radiation as that is the key to not only understanding how radiation can kill cancer cells, but also cause cancer and other health issues. The invention of microdosimetry in the 1950s by Harold Rossi paved the way for brilliant scientists to study the mechanism of radiation at cellular and sub-cellular scales. This paper reviews some snippets of ingenious mathematical and computational models published in microdosimetry symposium proceedings and publications of the radiation research community. Among these are simulations of radiation tracks at atomic and molecular levels using Monte Carlo methods, models of cell survival, quantification of the amount of energy required to create a single strand break, and models of DNA-damage-repair. These models can broadly be categorized into mechanistic, semi-mechanistic, and phenomenological approaches, and this review seeks to provide historical context of their development. We salute pioneers of the field and great teachers who supported and educated the younger members of the community and showed them how to build upon their work.

Targeting radioresistance and replication fork stability in prostate cancer

The bromodomain and extraterminal (BET) family of chromatin reader proteins bind to acetylated histones and regulate gene expression. The development of BET inhibitors (BETi) has expanded our knowledge of BET protein function beyond transcriptional regulation and has ushered several prostate cancer (PCa) clinical trials. However, BETi as a single agent is not associated with antitumor activity in patients with castration-resistant prostate cancer (CRPC). We hypothesized novel combinatorial strategies are likely to enhance the efficacy of BETi. By using PCa patient-derived explants and xenograft models, we show that BETi treatment enhanced the efficacy of radiation therapy (RT) and overcame radioresistance. Mechanistically, BETi potentiated the activity of RT by blocking DNA repair. We also report a synergistic relationship between BETi and topoisomerase I (TOP1) inhibitors (TOP1i). We show that the BETi OTX015 synergized with the new class of synthetic noncamptothecin TOP1i, LMP400 (indotecan), to block tumor growth in aggressive CRPC xenograft models. Mechanistically, BETi potentiated the antitumor activity of TOP1i by disrupting replication fork stability. Longitudinal analysis of patient tumors indicated that TOP1 transcript abundance increased as patients progressed from hormone-sensitive prostate cancer to CRPC. TOP1 was highly expressed in metastatic CRPC, and its expression correlated with the expression of BET family genes. These studies open new avenues for the rational combinatorial treatment of aggressive PCa.

Radiation therapy enhanced therapeutic efficacy of anti-PD1 against gastric cancer

Radiation therapy is an important method in tumor treatment with distinct responses. This study aimed to investigate the immune effects of radiation therapy on the syngeneic gastric tumor model. Mouse forestomach carcinoma (MFC) cells were irradiated with different X-ray doses. Cell proliferation was determined by clonogenic assay. Gene and protein expression were determined by real-time quantitative PCR and western blot, respectively. The tumor model was established by subcutaneously injecting tumor cells in 615-(H-2 K) mice. Levels of immune-related factors in tumor tissues were determined by immunohistochemistry and flow cytometry. 5 Gy × 3 (three subfractions with 4 h interval) treatment significantly inhibited cell proliferation. Protein expression of stimulator of interferon genes (Sting) and gene expression of IFNB1, TNFα as well as CXCL-9 significantly increased in MFC cells after irradiation. In the MFC mouse model, no obvious tumor regression was observed after irradiation treatment. Further studies showed Sting protein expression, infiltration of dendritic cells and T cells, and significantly increased PD-1/PD-L1 expression in tumor tissues. Moreover, the irradiation treatment activated T cells and enhanced the therapeutic effects of anti-PD1 antibody against MFC tumor. Our data demonstrated that although the MFC tumor was not sensitive to radiation therapy, the tumor microenvironment could be primed after irradiation. Radiation therapy combined with immunotherapy can greatly improve anti-tumor activities in radiation therapy-insensitive tumor models.

An Exploration of the Rs of Radiobiology in Prostate Cancer

OBJECTIVES

To explore the four Rs of radiobiology (Repair, Reoxygenation, Reassortment, and Repopulation) as a means to understand the effects of ionising radiation on biological tissue and subsequently as the basis for conventional fractionated treatment schedules. These radiobiological principles will form a rationale for combined regimens in prostate cancer treatment involving androgen deprivation therapy and radiation therapy and the associated toxicities of this approach will be discussed.

DATA SOURCES

Electronic databases including CINAHL, MEDLINE, Scopus, professional websites, books and grey literature were searched using Google Scholar.

CONCLUSION

It is important for nurses to understand the four Rs of radiobiology to grasp the effects of ionising radiation on biological tissue as the basis for conventional fractionated treatment schedules in prostate cancer. Men can experience a sequalae of physical and psychological side effects of treatment that can negatively impact quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Men can experience a range of unmet supportive care needs particularly related to informational, sexual, and psychological needs. For men affected by prostate cancer opting for radiation therapy (+/-) androgen deprivation therapy, nurses should ask targeted questions based on the Common Terminology Criteria for Adverse Events related to urinary and bowel function, potency and fatigue, and sexual health. We also recommend the use of holistic needs assessments to tailor self-management care plans. Evidence-based self-management advice should be provided in response to each man's unique needs.

Cancer Stem Cells and Combination Therapies to Eradicate Them

Cancer stem cells (CSCs) show self-renewal ability and multipotential differentiation, like normal stem or progenitor cells, and which proliferate uncontrollably and can escape the effects of drugs and phagocytosis by immune cells. Traditional monotherapies, such as surgical resection, radiotherapy and chemotherapy, cannot eradicate CSCs, however, combination therapy may be more effective at eliminating CSCs. The present review summarizes the characteristics of CSCs and several promising combination therapies to eradicate them.

Exploring the Potential Utility of Pet Dogs With Cancer for Studying Radiation-Induced Immunogenic Cell Death Strategies

Radiotherapy serves as a foundational pillar for the therapeutic management of diverse solid tumors through the generation of lethal DNA damage and induction of cell death. While the direct cytotoxic effects of radiation therapy remain a cornerstone for cancer management, in the era of immunooncology there is renewed and focused interest in exploiting the indirect bystander activities of radiation, termed abscopal effects. In radioimmunobiologic terms, abscopal effects describe the radiotherapy-induced regression of cancerous lesions distant from the primary site of radiation delivery and rely upon the induction of immunogenic cell death and consequent systemic anticancer immune activation. Despite the promise of radiation therapy for awaking potent anticancer immune responses, the purposeful harnessing of abscopal effects with radiotherapy remain clinically elusive. In part, failure to fully leverage and clinically implement the promise of radiation-induced abscopal effects stems from limitations associated with existing conventional tumor models which inadequately recapitulate the complexity of malignant transformation and the dynamic nature of tumor immune surveillance. To supplement this existing gap in modeling systems, pet dogs diagnosed with solid tumors including melanoma and osteosarcoma, which are both metastatic and immunogenic in nature, could potentially serve as unique resources for exploring the fundamental underpinnings required for maximizing radiation-induced abscopal effects. Given the spontaneous course of cancer development in the context of operative immune mechanisms, pet dogs treated with radiotherapy for metastatic solid tumors might be leveraged as valuable model systems for realizing the science and best clinical practices necessary to generate potent abscopal effects with anti-metastatic immune activities.

Incorporating cancer stem cells in radiation therapy treatment response modeling and the implication in glioblastoma multiforme treatment resistance

PURPOSE

To perform a preliminary exploration with a simplistic mathematical cancer stem cell (CSC) interaction model to determine whether the tumor-intrinsic heterogeneity and dynamic equilibrium between CSCs and differentiated cancer cells (DCCs) can better explain radiation therapy treatment response with a dual-compartment linear-quadratic (DLQ) model.

METHODS AND MATERIALS

The radiosensitivity parameters of CSCs and DCCs for cancer cell lines including glioblastoma multiforme (GBM), non-small cell lung cancer, melanoma, osteosarcoma, and prostate, cervical, and breast cancer were determined by performing robust least-square fitting using the DLQ model on published clonogenic survival data. Fitting performance was compared with the single-compartment LQ (SLQ) and universal survival curve models. The fitting results were then used in an ordinary differential equation describing the kinetics of DCCs and CSCs in response to 2- to 14.3-Gy fractionated treatments. The total dose to achieve tumor control and the fraction size that achieved the least normal biological equivalent dose were calculated.

RESULTS

Smaller cell survival fitting errors were observed using DLQ, with the exception of melanoma, which had a low α/β = 0.16 in SLQ. Ordinary differential equation simulation indicated lower normal tissue biological equivalent dose to achieve the same tumor control with a hypofractionated approach for 4 cell lines for the DLQ model, in contrast to SLQ, which favored 2 Gy per fraction for all cells except melanoma. The DLQ model indicated greater tumor radioresistance than SLQ, but the radioresistance was overcome by hypofractionation, other than the GBM cells, which responded poorly to all fractionations.

CONCLUSION

The distinct radiosensitivity and dynamics between CSCs and DCCs in radiation therapy response could perhaps be one possible explanation for the heterogeneous intertumor response to hypofractionation and in some cases superior outcome from stereotactic ablative radiation therapy. The DLQ model also predicted the remarkable GBM radioresistance, a result that is highly consistent with clinical observations. The radioresistance putatively stemmed from accelerated DCC regrowth that rapidly restored compartmental equilibrium between CSCs and DCCs.

Strategies To Assess Hypoxic/HIF-1-Active Cancer Cells for the Development of Innovative Radiation Therapy

Local tumor recurrence and distant tumor metastasis frequently occur after radiation therapy and result in the death of cancer patients. These problems are caused, at least in part, by a tumor-specific oxygen-poor microenvironment, hypoxia. Oxygen-deprivation is known to inhibit the chemical ionization of both intracellular macro-molecules and water, etc., and thus reduce the cytotoxic effects of radiation. Moreover, DNA damage produced by free radicals is known to be more repairable under hypoxia than normoxia. Hypoxia is also known to induce biological tumor radioresistance through the activation of a transcription factor, hypoxia-inducible factor 1 (HIF-1). Several potential strategies have been devised in radiation therapy to overcome these problems; however, they have not yet achieved a complete remission. It is essential to reveal the intratumoral localization and dynamics of hypoxic/HIF-1-active tumor cells during tumor growth and after radiation therapy, then exploit the information to develop innovative therapeutic strategies, and finally damage radioresistant cells. In this review, we overview problems caused by hypoxia/HIF-1-active cells in radiation therapy for cancer and introduce strategies to assess intratumoral hypoxia/HIF-1 activity.

How can we overcome tumor hypoxia in radiation therapy?

Local recurrence and distant metastasis frequently occur after radiation therapy for cancer and can be fatal. Evidence obtained from radiochemical and radiobiological studies has revealed these problems to be caused, at least in part, by a tumor-specific microenvironment, hypoxia. Moreover, a transcription factor, hypoxia-inducible factor 1 (HIF-1), was identified as pivotal to hypoxia-mediated radioresistance. To overcome the problems, radiation oncologists have recently obtained powerful tools, such as "simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT), which enables a booster dose of radiation to be delivered to small target fractions in a malignant tumor", "hypoxia-selective cytotoxins/drugs", and "HIF-1 inhibitors" etc. In order to fully exploit these innovative and interdisciplinary strategies in cancer therapy, it is critical to unveil the characteristics, intratumoral localization, and dynamics of hypoxia/HIF-1-active tumor cells during tumor growth and after radiation therapy. We have performed optical imaging experiments using tumor-bearing mice and revealed that the locations of HIF-1-active tumor cells changes dramatically as tumors grow. Moreover, HIF-1 activity changes markedly after radiation therapy. This review overviews 1) fundamental problems surrounding tumor hypoxia in current radiation therapy, 2) the function of HIF-1 in tumor radioresistance, 3) the dynamics of hypoxic tumor cells during tumor growth and after radiation therapy, and 4) how we should overcome the difficulties with radiation therapy using innovative interdisciplinary technologies.

Hypoxia and reoxygenation in human melanoma xenografts

Tumor hypoxia and reoxygenation pattern following single dose (10.0 Gy) and fractionated (7 fractions of 2.0 Gy, 1 fraction per day) irradiation were studied in five human melanoma xenograft lines using the paired survival curve method. The hypoxic fractions differed significantly among the melanoma lines; they were found to be 6 +/- 3% (E.E.), 22 +/- 8% (E.F.), 31 +/- 11% (G.E.), 45 +/- 17% (M.F.), and 15 +/- 5% (V.N.). There were no clear correlations between hypoxic fraction and tumor volume-doubling time or vascular density, suggesting that intrinsic cellular characteristics, for example, rate of oxygen consumption and ability to retain clonogenicity under hypoxic stress, also may play an important role for the magnitude of the hypoxic fractions in the melanomas. Reoxygenation was rapid and extensive in all melanoma lines; 12-24 hr after the single dose irradiation or the last fraction of the fractionated irradiation, the hypoxic fractions were similar to those in untreated tumors and stayed at that level up to at least 10 days after irradiation. The hypoxic fractions 1-10 days after irradiation tended to be higher after fractionated than after single dose irradiation, but the differences were not statistically significant. There was a positive correlation between the hypoxic fractions in untreated tumors and the hypoxic fractions after irradiation and reoxygenation, suggesting that it may be possible to predict radiation resistance caused by hypoxia from the hypoxic fractions in tumors before start of radiation therapy. However, hypoxia is probably not a major cause of failure in the radiation therapy of malignant melanoma.

Polarography of Walker Tumor Submitted to Radiotherapy

A Polarographic study of oxigen was done in 57 rats inoculated with Walker 256 tumor and platinum electrode implanted in muscle and in tumor. The goal of the research was the study of oxygen in tumor before and after irradiation. Tumor growth caused a decrease in tumoral oxygen. Oxygen was always lower in the tumor than in the muscle. Radiotherapy with 2000 rad (but not with 1000 rad) increased oxygen in the tumor.

Changes of hexose monophosphate pathway and methemoglobin reductase enzyme activity after radiation in guinea pigs

HMP pathway activity changes occurring after exposure to ionizing radiation (LD50 dose) have been investigated. The study was carried out on 18 experimental guinea pigs subjected to 5 successive exposures of 150 rads 3 or 4 days apart. The control animals were sham radiated but were otherwise treated identically as those of the experimental groups. Blood samples were taken by cardiac puncture before radiation and 30 min after each exposure of 150 rads. The red cells were re-suspended in their own plasma and HMP pathway activity was measured in the suspension. The pathway activity showed a consistent but minor reduction in the experimental group, which became statistically significant after the total dose of 750 rads (P less than 0.020). In a separate study the changes induced by ionizing radiation in the erythrocyte enzyme NADH-methemoglobin reductase were measured using the same experimental protocol. The enzyme activity in the red cells of the experimental group varied between 34.90 +/- 2.17 to 161.95 +/- 5.34 I.U./ml erythrocyte pack. Its activity declined toward the initial value after reaching the peak by the 12th day of ionizing radiation with 600 rads (P less than 0.001).

Sensitizers and radiation dose fractionation: results and interpretations

Misonidazole is generally regarded as having been a clinical failure as a radiation sensitizer. It is hoped that the newer sensitizers SR-2508 and Ro 03-8799 will give better results because single dose studies with animal tumors have indicated that these two drugs give higher enhancement ratios than misonidazole at clinically tolerated doses. Other factors may also have influenced the clinical efficacy of misonidazole, however, particularly reoxygenation during the course of the fractionated treatments. In this paper reoxygenation in animal tumors and experimental studies in which fractionated radiation doses have been combined with sensitizers are reviewed. It is concluded that, even for dose fractions of 2 Gy, reoxygenation may not completely eliminate the influence of hypoxic cells on tumor response, when large total doses are given. Problems associated with tumor heterogeneity are also discussed to highlight the desirability of selecting the most suitable patients for clinical studies. Poorly reoxygenating tumors, rapidly growing tumors and tumors in patients in whom oxygen delivery to tissue is compromised are those whose control is most likely to be improved by combining radiation sensitizers with conventional treatment. However effective sensitizers should also allow fractionation schedules to be modified, to achieve a therapeutic gain, by taking advantage of differences in repair or repopulation between the tumor and critical normal tissue, without having to consider possible detrimental effects on reoxygenation.

Patterns of cell loss and repopulation in irradiated cultures of plateau phase C3H 10T 1/2 cells

Patterns of cell loss and repopulation were studied in plateau phase cultures of slowly-cycling, contact-inhibited C3H 10T1/2 mouse fibroblasts following large single, and multiple small doses of 137Cs-gamma rays. A progressive, dose-independent cell loss was apparent within days after irradiation with large single doses, and similar patterns of loss were observed following the start of multifraction irradiations. This progressive cell loss culminated in the loss of integrity of the monolayer of cells, a loss of contact-inhibition, and therefore, an increased rate of cell division. The time of onset of measurable repopulation, and the time required to completely repopulate a culture varied with the number of clonogenic cells present at the time of breakdown of the monolayer. For cultures receiving multiple irradiations over time periods greater than those required for breakdown of the monolayer, repopulation began to occur during treatment, and its rate varied with the average dose per fraction being delivered. Thus, repopulation did not start immediately after the start of irradiation, but needed a triggering event, in this case, a decrease to a critical level in the cell density. Once initiated, repopulation was able to decrease or even eliminate the effectiveness of subsequent doses in reducing the number of viable cells per culture. To the extent that the responses of slowly-cycling, contact-inhibited cells in vitro can be applied to interpret the radiation responses of cell populations in vivo, these results further support the notion that it may be necessary, in some cases, to account for an increasing contribution from repopulation with increasing overall treatment time in dose fractionation isoeffect formulae used for predicting tissue tolerances or tumor control.

Changes of reduced glutathion, glutathion reductase, and glutathione peroxidase after radiation in guinea pigs

In this series of experiments the protective action of reduced glutathion due to ionizing radiation has been studied. In the experimental group 18 guinea pigs were exposed to successive radiations of 150 rad 3 or 4 days apart. Total dose given amounted to 750 rad which is the LD50 for guinea pigs. Blood samples were taken 30 min after each exposure. The control series were sham radiated but otherwise treated identically. The cells of the removed blood samples were separated by centrifugation and were subjected to the reduced glutathion stability test. GSSGR, GPer, and LDH enzyme activities were also measured of which the latter served as a marked enzyme. It was found that LDH did not show any alteration after radiation. The reduced glutathion stability test showed a consistent but minor reduction (P greater than 0.05), in the experimental group. GSSGR enzyme activity on the other hand was reduced significantly (from 176.48 +/- 11.32 to 41.34 +/- 1.17 IU/ml of packed erythrocytes, P less than 0.001) in the same group. GPer activity showed a consistent but minor elevation during the early phase of the experimental group. It was later increased significantly beginning after 600 rad total radiation on the fourth session (P less than 0.050).

Fractionated radiation therapy after Strandqvist

Models for predicting the total dose required to produce tolerable normal-tissue damage in radiation therapy are becoming less empirical, more realistic, and more specific for different tissue reactions. The progression is described from the 'cube root law', through Strandqvist's well known graph to NSD, TDF and CRE and more recently to biologically based time factors and linear-quadratic dose-response curves. New applications of the recent approach are reviewed together with their implications for non-standard fractionation in radiation therapy. It is concluded that accelerated fractionation is an important method to be investigated, as well as hyperfractionation; and that more data are required about the proliferation rates of clonogenic cells in human tumours.

Direct measurement of reoxygenation in malignant mammary tumors after a single large dose of irradiation

Measurements of the tissue O2 partial pressure distribution in C3H mouse mammary adenocarcinomas were performed just before and 72 - 74 hrs. after X- irradiation using O2 microelectrodes of the gold in glass type. The results obtained before irradiation were similar to those usually obtained previously in fast growing murine tumors during advanced growth stages. After exposure to a single dose of 60 Gy, the distribution curve significantly changed. This change was particularly evident in the very low pO2 range which is of crucial importance for the efficacy of radiotherapy. Due to this improvement of the tumor tissue oxygenation the number of radioresistant cells can be drastically reduced in the post- irradiation period at the time of maximum reoxygenation. Judiciously chosen fractionated treatment regimens, thus, should maintain tumor cells in optimum radiosensitivity states.